Interventions for treating tibial shaft fractures in children

The ortho-plastic management of Gustilo grade IIIB fractures of the tibia in children: A systematic review of the literature

Background: Closed reduction and casting remain the gold standard treatment for tibial shaft fractures in children and adolescents. However, surgical intervention is indicated in cases of unstable fractures, open fractures, polytrauma, compartment syndrome, and fractures with severe soft tissue injury. The present study aimed to evaluate the safety and efficacy of Titanium Elastic Nailing System (TENS) in the management of compound tibial shaft fractures in children and adolescents. Methods: This retrospective study reviewed 18 cases of tibial shaft fractures treated with TENS from 2018 to 2021. Clinical outcomes were assessed based on fracture alignment, delayed union, non-union, infection, range of motion (ROM) of the knee and ankle, limb length discrepancy, and time to fracture union during follow-up visits. Outcomes were classified according to Flynn's criteria. Results: All patients achieved fracture union at a mean duration of 11.6 weeks, with full weight-bearing permitted at an average of 10 weeks. Limb shortening was observed in 4 patients. There were no cases of delayed union or non-union. At the final follow-up, 10 patients demonstrated excellent outcomes, while 8 had satisfactory outcomes. The most common complication was infection at the fracture site, observed in 6 patients. Conclusion: TENS is a safe, reliable, and effective treatment modality for compound tibial shaft fractures in children and adolescents. It facilitates rapid fracture healing with an acceptable complication rate.

IntroductionExternal fixator (EF) is a popular choice for open tibial fractures, but pin tract infection (PTI) and refracture are common complications. Elastic stable intramedullary nail (ESIN) has been reported in the treatment for open tibial fractures. This study aims to compare the clinical outcomes of EF vs. ESIN in the treatment for open tibial shaft fracture in children retrospectively.MethodsPatients aged 5–11 years with Gustilo-Anderson II and IIIA tibial shaft fracture treated at our institute from January 2008 to January 2018 were reviewed retrospectively and categorized into EF and ESIN groups. Patients with pathological fracture, neuromuscular disorder, metabolic disease, previous tibial fracture or instrumentation, and polytrauma were excluded. Patients with follow-up < 24 months or incomplete medical records were also excluded.ResultsIn all, 55 patients (33 males, 22 females) were included in the EF group, whereas 37 patients (21 males, 16 females) were included in the ESIN group. There was no statistically significant difference between the two groups concerning sex, age, body weight, duration from injury to surgery, Gustilo-Anderson (GA) classification, and concomitant injuries. There was no case of nonunion and malunion in either group. The angulation at the latest follow-up was higher in the EF group than the ESIN group (P < 0.01). The radiological union was faster in the ESIN group (7.0 ± 0.9 weeks) than those in the EF group (9.0 ± 2.2 weeks) (P < 0.01). Limb length discrepancy (LLD) was more in the EF group (12.1 ± 4.4, mm) than in the ESIN group (7.3 ± 4.3, mm) (P < 0.01).ConclusionESIN is a viable option in selected patients of GA grade II and IIIA open tibial fractures with comparable clinical outcomes as external fixator. Pin tract infection is the most troublesome complication in the EF group while implant prominence is a nuisance in the ESIN group.

ABSTRACTIntroductionSegmental fractures in the juvenile distal tibia with physeal involvement present specific challenges. Injury to the growth plate may be overlooked, potentially resulting in late sequelae. Fracture stabilization can be complex. Previous reports of management of such an injury are by open reduction and internal fixation. This study reviews the management and outcome of a group of such patients treated with Ilizarov external fixators.Materials and methodsPatients aged 16 or younger treated in our unit between March 2013 and November 2014 by Ilizarov circular fine wire fixation for tibial fractures with ipsilateral physeal injuries were identified. Retrospective collection of patient demographics, fracture classification, treatment pathways, fixation methods, postoperative follow-up, outcomes, and complications was undertaken.ResultsEight patients were identified; two had Gustilo and Anderson grade IIIA open injuries. All were managed definitively using an Ilizarov external fixator in combination with percutaneous screw fixation of the physeal component as required. All patients were ambulant during treatment and were allowed unrestricted weight-bearing immediately postoperative. All but one attended school. All fractures united. In follow-up, one patient had a distal tibial physeal growth arrest, but there were no other complications.ConclusionPediatric patients with complex distal tibial fractures should be scrutinized for concomitant physeal injury. Where identified treatment, using a combination of internal fixation and an Ilizarov fixator can be considered.How to cite this articleRogers GP, Tan HB, Foster P, et al. Complex Tibial Shaft Fractures in Children Involving the Distal Physis Managed with the Ilizarov Method. Strategies Trauma Limb Reconstr 2019;14(1):20–24.

Open tibial shaft fracture in a boy with autism spectrum disorder treated using a ring external fixator: A case report

Calcaneal skeletal traction versus elastic intramedullary nailing of displaced tibial shaft fractures in children- letter to editor

To analyze leg length discrepancy and overgrowth after tibial shaft fractures in children. We analyzed medical records of 103 patients younger 14 years old with tibial shaft fractures between January 2003 and November 2018. Treatment included plastering and insertion of titanium elastic nail. To identify the risk factors of leg length discrepancy ≥1 cm and overgrowth ≥1 cm, we performed logistic regression analysis. Statistical analysis was carried out using the SPSS software for Windows. Gender (p=0.014) and treatment methods (p=0.011) are the most significant predictors of leg length discrepancy and overgrowth. In boys, the risk of leg length discrepancy ≥1 cm was 7.4 times higher than in girls. The risk of leg length discrepancy ≥1 cm was 4.3 times higher after insertion of titanium elastic nail compared to plastering. The risk of overgrowth ≥1 cm was 5.4 times higher in boys than in girls. The risk of overgrowth ≥1 cm was 4.7 times higher after insertion of titanium elastic nail compared to plastering. One should consider the risk of leg length discrepancy and overgrowth in children with tibial shaft fractures. This is especially true for boys undergoing insertion of titanium elastic nail.

Introduction Tibial shaft fractures are one of the most common long-bone fractures in the pediatric age group. A closed reduction followed by casting is the classical method of treatment in these fractures.the flexible intramedullary may be required in unstable fractures using a 2-incision technique In this technique with the use of a single medial incision, curves are created with one c shape and the other is s shape, Patients and Methods A prospective randomized control study was undertaken to assess the results of elastic stable intramedullary nails (ESIN)in the fixation of tibial shaft fractures in children using a single incision versus two-incision. Results 30 patients with tibial shaft fractures were treated with EIMN From April 2020 to March 2021 and followed up for 6 months after surgery, the mean age was 8.43 ± 1.55. Group A reported mild postoperative pain, with a significant difference (P value &lt; 0.05) from group B who expressed moderate pain according to FLACCbehavioral Pain Assessment Scale. Conclusion This technique has many advantages. as it is a minimally invasive surgery with a short duration of hospitalization. And single incision adds more privilege to be a minimally invasive surgery and the use of a single medial incision puts putting away any possibility of common peroneal nerve injury.

Currently the gold standard in surgical treatment of displaced tibial shaft fractures in children with open growth cartilage is elastic stable intramedullary nailing (ESIN). The purpose of this study is the analysis of indications, complications, and duration of treatment using intramedullary flexible nails in children who are still growing but especially weighing 50 kg or more. Hospital records from 2017 to 2020 were retrospectively reviewed to identify the children from 4 to 17 years of age with displaced tibial shaft fractures admitted to the hospital. Only children with open growth cartilage, with a minimum of 6 months of follow-up and complete clinical data, were included. Studies of 91 children xwere analyzed. The average patient age at the time of the injury was 10.88 ± 2.82 years. In the entire group, 31.9% children weighed 50 kg or more, and 68.1% of the children were below this weight. All children were treated using ESIN. The mean time to nail removal was 8.4 ± 4.09 months in the whole group of children stabilized with ESIN. There were no differences in the two groups depending on the weight ( P = 0.637). Only two adverse events were observed. This study demonstrates that the use of ESIN in displaced tibial shaft fractures in growing children weighing 50 kg or more is acceptable and safe. The discussion to be made is whether it is still an acceptable method of treatment for this type of fracture due to the progressive obesity epidemic in children and adolescents.

Purpose : To assess the comparative growth of the four long bones of the lower extremities after the tibial shaft fractures in children. Materials and Methods : Thirty-eight children (age, 8.2±2.6) with tibial shaft fractures treated with a closed reduction and a long leg cast were enrolled in this study. The mean follow-up was 54.4 months (range, 24-96). The medical records and Bell-Thompson images were retrospectively reviewed. Results : The clinical results were excellent in all cases. The fractured tibia showed overgrowth (4.4±3.3 mm) compared with the contralateral side. The ipsilateral femur showed mild over- growth (0.9 mm±3.7), and the final leg length discrepancy was 5.3 mm±5.4. Four ipsilateral femurs showed overgrowth ＞10 mm. Gender, the level of the fractures and associated fibular fractures did not affect the overgrowth of the fractured tibia (p＞0.05). However, age might affect the amount of overgrowth (p=0.005). Conclusion : Tibial shaft fractures in children treated with a long leg cast showed variable overgrowth. The final leg length discrepancy was influenced by the overgrowth of the ipsilateral femur as well as by overgrowth of the tibia.

The purpose of this study is to provide a summary of the absolute and the relative surgical indications for both closed and operative treatment of tibial shaft fractures. A literature review of the pertinent literature was undertaken, and a limited number of the most significant papers are cited. Recommendations are provided for fractures that are most likely to need surgical intervention and relative indications for fractures that may benefit from surgical stabilization. Successful closed treatment can be achieved either by casting and conventional 3-point molding or by utilizing the Sarmiento technique of casting. Either technique depends on soft tissues to maintain bony alignment. The reported results are significantly improved after surgical stabilization after open tibial shaft fractures and tibial shaft fractures associated with ipsilateral femoral fractures. Relative indications for surgical stabilization include comminuted fractures, displaced fractures with an intact fibula, and displaced fractures in adolescents. Compartment syndrome remains the most significant early complication encountered when treating tibial shaft fractures in children and adolescents by either closed or surgical methods and should be considered in the face of pain out of proportion to the injury or increasing narcotic requirements. Tibial fractures are one of the more common injuries treated by orthopedic surgeons. Although most can be treated by closed techniques, certain fractures benefit significantly from surgical stabilization.

Elastic stable intramedullary nailing (ESIN) may be complicated by the loss of reduction following push out of the nails at the entry site in unstable femoral and tibial fractures, especially in older and heavier children and following technical failures. An end cap system addressing this complication was evaluated clinically. In a retrospective case series, 49 femoral and five tibial fractures in 54 pediatric patients treated by ESIN and end caps were documented in two European tertiary centers. End caps were used to interlock standard ESIN nails. The results were evaluated regarding difficulties in the placement and removal of the end cap system, fracture stability and healing, and return to normal activities by analyzing patient charts and X-rays. Fifty-three of 54 fractures were stabilized sufficiently with ESIN and end caps. Loss of reduction was observed in one patient, requiring additional surgery. Six complications were observed, five of which were not related to end caps. There were no significant leg length differences or varus/valgus deformities. A rotational difference of >10°-20° was found in one patient. Removal of the end caps and nails was rated as simple and uncomplicated in 35/37 cases. End caps avoided postoperative instability in the majority of pediatric patients with lower limb shaft fractures, even in heavier, older patients and those with instable fracture types. End caps, however, will not compensate for operative technical insufficiency concerning reduction or nail placement. To maximize the stability of ESIN-instrumented unstable fractures, end caps require properly placed nails.

Tibial fractures in the skeletally immature patient are usually treated without surgery. Elastic stable intramedullary nailing (ESIN) is commonly used for other diaphyseal fracture locations. Its advantages are minimally invasive surgery with a short hospitalisation duration, primary bone union and early weight bearing. The purpose of this study was to assess the use of ESIN in displaced tibial fractures in children over 6years old and in cases of polytrauma. This study was carried out over a 6-year period. The protocol consisted in ESIN of shaft tibial fractures in children over 6. Frontal and sagittal angulation, shortening and lengthening were measured on days 0, 2, 15, 30 and 45. At 6months, 1 and 2years, the femoro-tibial axis and eventual shortening or lengthening were assessed. The study involved 86 children (average age 11.8years). As early as day 30, all patients had normal knee mobility and symmetrical foot progress angle. At 2-year follow-up, frontal angulation and leg length discrepancy had decreased and affected 2% of patients. Four patients (5%) suffered from superficial infections. There were no cases of osteomyelitis or refracture. The fixation of paediatric diaphyseal tibial fractures with ESIN is a rapid, well-codified and effective method for treating long-bone closed fractures in children. Advantages over other fixation techniques include a lower infection rate, a lower refracture rate, ease of management, and an aesthetically pleasing scar.

PurposeTibia fractures are the third most common long bone fracture in children. Because of the remodelling potential of the tibial diaphysis, nonoperative treatment has historically been advocated for most tibial shaft fractures in children. The purpose of this study was to estimate the rate of surgical treatment of tibial shaft fractures over time and identify demographic factors associated with surgical treatment, utilizing a large, publicly available, national database.MethodsThe Healthcare Cost and Utilization Project Kids’ Inpatient Database was evaluated for the years between 2000 and 2012. Tibial shaft fractures and surgically treated patients were identified using International Classification of Diseases, 9th Revision, Clinical Modification codes. Univariable and multivariable logistic regression were used to determine variables associated with a greater proportion of surgical treatment. Statistical analyses were performed utilizing SAS statistical software v.9.4. Statistical significance was set at p < 0.05.ResultsIn all, 24 166 tibial shaft fracture admissions were identified, with 15 621 (64.7%) treated surgically. The percentage of patients receiving surgery to treat tibial shaft fractures increased from 57.3% in 2000 to 74.3% in 2012 (p < 0.001). Multivariable regression showed that increasing age was associated with increased rate of surgical treatment (p < 0.001). The greatest increase in surgical treatment was seen in children aged five to nine years, increasing from 23.0% in 2000 to 46.2% in 2012.ConclusionThe rate of operative treatment of paediatric tibial shaft fractures increased over time. The largest increase was seen in children aged five to nine years. Increased proportion of surgical treatment was associated with older age, concurrent femur fracture and non-Medicaid insurance status.Level of EvidenceLevel III - Retrospective comparative study

Background/Purpose:Long leg casts (LLC) with delayed weight-bearing is an established treatment for pediatric tibial shaft fractures including fractures involving the distal third. There is a paucity of literature assessing the use of SLC for tibial shaft fractures. The purpose of this study was to determine if SLC and early weight-bearing was as effective as LLC with delayed weight-bearing for the treatment of pediatric distal third tibial shaft fractures. Methods:A retrospective review was conducted on consecutive distal third tibial shaft fractures treated at a tertiary pediatric hospital from 2015 to 2018. Exclusion criteria included midshaft and proximal fractures of the tibia, distal fractures that violated the tibial physis or plafond, and pathologic fractures. We compared primary outcomes of time to weight-bearing, time to union, and final angulation between LLC and SLC groups. Results:Eighty-five patients aged 5 to 17 years (mean age 9.2±3.2 years) met inclusion criteria, including 50 LLC and 35 SLC patients. Fracture type (p=0.14), presence of associated fibula fracture (p=0.49), open fracture (p=0.46), and injury mechanism (p=0.18) were similar between the two groups. Time to weight-bearing for SLC (3.3±0.6 weeks) was shorter compared to LLC (6.4±0.7 weeks, p<0.0001). Overall, fractures treated with SLC had a shorter time to union (7.4±0.9 weeks) compared to LLC (9.0±0.9 weeks, p=0.026) without differences in final angulation (p=0.54). There was a higher percentage of cast complications in the LLC treatment group (12%) compared to SLC (6%). Conclusion:SLC with early weight-bearing demonstrated earlier time to weight-bearing and shorter time to fracture union when compared to LLC. Surgeons should consider SLC and early weight-bearing for the treatment of distal third tibial shaft fractures in children.